Provider Demographics
NPI:1710482948
Name:AKTIVE MOTION PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:AKTIVE MOTION PHYSICAL THERAPY INC
Other - Org Name:AKTIVE MOTION PHYSICAL THERAPY AND WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:DORNEVIL
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:239-672-0174
Mailing Address - Street 1:4520 BOTANICAL PLACE CIR APT 306
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34112-2403
Mailing Address - Country:US
Mailing Address - Phone:239-672-0174
Mailing Address - Fax:
Practice Address - Street 1:1250 9TH ST N STE 204
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102
Practice Address - Country:US
Practice Address - Phone:904-712-9629
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-28
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X, 261QH0100X, 261QP2000X, 261QP3300X, 261QR0400X, 261QR0401X, 261QR0800X
FLPT30933261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
No261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care